A nurse in an obstetric clinic is caring for four clients.
The nurse should identify that an intrauterine device is contraindicated for which of the following clients?

Condition: Placenta previa

2 actions:

• Reinforce bed rest and maintain IV access
• Prepare for an emergency cesarean birth

2 parameters:

• Fetal heart rate
• Maternal oxygen saturation

Rationale for correct condition: Placenta previa is indicated by painless, bright red vaginal bleeding in the third trimester, without abdominal pain or uterine tenderness. The fetal heart rate shows abnormalities with minimal variability, which can occur due to placental issues. Fundal height consistent with gestational age and absence of contractions support this diagnosis. Diagnosing this early is crucial as it poses significant risks to both the mother and fetus. The client’s history of bleeding and current symptoms align with placenta previa more than other conditions.

Rationale for actions: Reinforcing bed rest helps minimize bleeding and maintains stability. IV access is crucial for fluid management and potential blood transfusion. Preparing for an emergency cesarean birth ensures prompt delivery if maternal or fetal status deteriorates, preventing severe complications. Administering broad-spectrum antibiotics isn’t directly indicated as there's no sign of infection. Methotrexate is inappropriate here as it treats ectopic pregnancies, not placental issues. Encouraging ambulation might exacerbate bleeding, worsening the condition.

Rationale for parameters: Monitoring fetal heart rate assesses fetal well-being and detects distress early. Maternal oxygen saturation is vital to ensure adequate oxygen delivery to both mother and fetus. WBC count isn't immediately relevant unless there's an infection concern. Urine output doesn’t directly indicate placental health. Uterine contractions are irrelevant since there are no signs of preterm labor or irritability.

Rationale for incorrect conditions: Abruptio placentae usually involves painful bleeding with uterine tenderness or contractions. Preterm labor is characterized by regular contractions leading to cervical changes, absent here. Uterine rupture often involves severe pain, sudden fetal distress, and maternal shock, none of which are present.

Choice A rationale

Applying pressure to the soles of the feet in a supine position does not elicit the Babinski reflex. This action might trigger other reflexes, but not the specific upward fanning of the toes associated with the Babinski reflex.

Choice B rationale

Pulling the newborn up by the wrist from a supine position is used to test the Moro reflex, not the Babinski reflex. The Moro reflex involves a startled response with spreading arms, not the toe movements of the Babinski reflex.

Choice C rationale

Touching the corner of the newborn's mouth elicits the rooting reflex, not the Babinski reflex. The rooting reflex helps the baby locate the breast or bottle for feeding, involving head-turning and mouth movements.

Choice D rationale

Stroking upward on the lateral aspect of the sole of the newborn's foot elicits the Babinski reflex. This action results in the big toe dorsiflexing and the other toes fanning out, which is a normal response in infants up to 2 years old and indicates intact neurological function.